Coding for procedures: The urologist's role

February 1, 2011

For practicing urologists who are interested in maximizing their income legally and ethically, it's important to understand some of the coding process.

This process does not require a rocket scientist, nor the expertise of a certified coder. These tasks can be accomplished quickly, efficiently, and accurately with a little pre-planning and a willingness to change old habits. As noted, you do not have to code for your services per se; however, it is important that you identify all services that you perform.

There are a finite number of surgeries that each urologist performs on a routine basis. You can easily identify those by looking at all surgeries performed the previous year. Once those procedures have been identified, sit down with your coder and your billing staff to develop an individualized superbill or "communication sheet." This can be formatted to hold all, or at least 90%, of the surgeries that you usually perform. Work with your coder to ensure that the codes are accurate and up to date. Include the appropriate ICD-9 diagnosis codes on the same sheet.

This step is very important each year. We have found a number of cases where the coding staff has identified a service with an incorrect code, which is perpetuated throughout the practice. Without review, the mistake can be repeated easily, adding thousands to the lost revenue column.

After the team has identified and coded correctly all procedures you'd normally perform, format it into a communication sheet (see http://urologytimes.com/communicationsheet). Now, you are in the position to perform your tasks without having to reinvent the wheel each time you perform surgery, which, in essence, is what happens if you or your staff has to look up the CPT codes after each surgery.